Finding into death of Dianne Linford

63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) tube insertion (procedure abandoned) in a woman with congenital polymicrogyria

Dianne Linford, a 63-year-old woman with profound disability from cerebral palsy and encephalitis, died from complications of sedation for PEG tube insertion. She had a congenital polymicrogyria, a significant neurological risk factor for anaesthesia. Following a dental injury in March 2018, she developed aspiration pneumonia and severe mouth ulcers limiting oral intake. She presented in June requiring hospitalisation for dehydration. During attempted PEG insertion on 27 June, she desaturated requiring intubation and ICU admission. The clinical lesson is the need for careful risk stratification before sedation in patients with structural brain abnormalities, consideration of alternative feeding strategies or safer anaesthetic approaches, and recognition that multiple failed feeding interventions and complications may indicate need for earlier palliative care discussion.